Healthcare Facility Inspection of the VA Nebraska-Western Iowa Health Care System in Omaha

Report Information

Issue Date
Report Number
25-00239-196
VISN
4
State
Nebraska
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Appointment Scheduling and Wait Times
Care Coordination
Community Care
Healthcare Infrastructure
Maintenance and Construction
Patient Safety
Staffing
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Nebraska-Western Iowa Health Care System in Omaha.

This evaluation focused on five key domains: 
     •    Culture 
     •    Environment of care 
     •    Patient safety 
     •    Integrated veteran care 
     •    Veteran-centered safety net

The OIG made four recommendations for VA to correct identified issues in two domains: 
     •    Environment of care 
       o    Patient care area cleanliness and biohazard management 
       o    Legionella prevention 
       o    Pharmaceutical waste disposal 
     •    Patient safety 
       o    Service-level workflows for the communication of test results
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director takes appropriate steps to maintain clean patient care areas and properly manage biohazards, in accordance with Veterans Health Administration Directive 1131, Management of Infectious Diseases and Infection Prevention and Controls Programs.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director takes appropriate steps so the facility’s annual assessment for Legionella disease prevention includes the Papillion community living center, as required by Veterans Health Administration Directive 1061(4), Prevention of Health Care-Associated Legionella Disease and Scald Injury from Water Systems.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff takes the appropriate steps for leaders to assess the facility’s pharmaceutical waste disposal processes and reeducate staff on safe handling and disposal practices, in accordance with the facility’s Regulated Waste Materials Management policy and Pharmaceutical Return, Waste, and Disposal Standard Operating Procedure.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care/Nurse Executive take the appropriate steps so leaders create service-level workflows that outline staff roles for communicating test results to patients and providers, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.